最新嚴(yán)重?zé)齻笊铎o脈導(dǎo)管相關(guān)感染并發(fā)顱內(nèi)多發(fā)性膿腫一例

1、嚴(yán)重?zé)齻笊铎o脈導(dǎo)管相關(guān)感染并發(fā)顱內(nèi)多發(fā)性膿腫一例ACaseofCerebralMultipleAbscessOccuringWithDeepVeinCatheterRelatedInfectionAfterSeverelyBurnt患者男，36歲，因全身火焰燒傷于傷后3h入院。入院時(shí)檢查：T36.1C,P96次/min,R22次/min,患者一般情況可，神志清楚，呼吸平順，燒傷創(chuàng)面分布于頭面、頸，軀干及四肢，創(chuàng)面基底大部分呈黃白色。入院診斷：燒傷總面積35%,淺II度15%,深I(lǐng)I度20%。入院后行右側(cè)股靜脈穿刺置管常規(guī)液體復(fù)蘇、創(chuàng)面清創(chuàng)，頭面部暴露,四肢及軀干創(chuàng)面外用1%磺胺嘧啶銀霜包扎等

2、治療。入院后20h,患者面頸部、雙前臂腫脹明顯,自訴喉頭有異物感及雙手指麻木等不適,遂于局麻下行氣管切開,雙上肢燒傷皮膚及淺筋膜切開減壓術(shù),隨后病情平穩(wěn)。傷后5d在靜脈全麻下行“雙上肢、左小腿深I(lǐng)I度創(chuàng)面15%削痂、自體網(wǎng)狀皮移植術(shù)”，術(shù)后應(yīng)用頭孢哌酮+依替米星抗感染,面部深I(lǐng)I度創(chuàng)面,軀干等部位創(chuàng)面繼續(xù)外用1%磺胺嘧啶銀霜隔日換藥,創(chuàng)面分泌物未培養(yǎng)出細(xì)菌,術(shù)后5d,削痂植皮創(chuàng)面換藥,皮片成活良好，傷后14d拔除氣管套管，拔管后患者呼吸平順，病情穩(wěn)定，除右下腹及左足背約1%深I(lǐng)I度創(chuàng)面未愈外,其余創(chuàng)面均愈合。治療過程中，傷后11d開始，患者出現(xiàn)高熱，最高達(dá)40.1C,外周血白細(xì)胞計(jì)數(shù)達(dá)20.1

3、X109/L,中心粒76%,調(diào)整抗生素為美洛西林+依替米星二聯(lián)抗感染,2d后，外周血白細(xì)胞計(jì)數(shù)下降至11.4X109/L,中心粒細(xì)胞86%體溫仍有波動(dòng)，最高為38.9C,胸部X-線檢查未見雙肺有異常改變。傷后15d再次出現(xiàn)寒戰(zhàn)、高熱，考慮有金黃色葡萄球菌感染可能,拔除右側(cè)股靜脈導(dǎo)管并送細(xì)菌培養(yǎng),調(diào)整抗菌素為穩(wěn)可信500mgq6h靜脈點(diǎn)滴，再次送檢創(chuàng)面分泌物細(xì)菌培養(yǎng)及血培養(yǎng)。3d后,靜脈導(dǎo)管、創(chuàng)面分泌物及血細(xì)菌培養(yǎng)均為耐甲氧西林金黃色葡萄球菌生長(zhǎng)(MRS)體外藥物敏感試驗(yàn)對(duì)萬古酶素敏感，繼續(xù)靜滴穩(wěn)可信，患者體溫有所下降，但漸漸出現(xiàn)神情淡漠、懶言及肢體乏力等癥狀,靜滴穩(wěn)可信6d后，出現(xiàn)左精品文檔上

4、肢肌力減退（III級(jí)），行顱腦MR檢查示：右側(cè)小腦半球及顳葉、額葉見多發(fā)片狀長(zhǎng)T1、T2信號(hào)影，境界模糊，壓水序列像上呈高信號(hào)，增強(qiáng)掃描見明顯環(huán)行強(qiáng)化或不完全的環(huán)形強(qiáng)化，局部腦溝、裂變窄，最大病灶位于右側(cè)顳葉，大小約3cmx2.8cm,兩側(cè)大腦，左側(cè)小腦尚可見散在小斑點(diǎn)樣強(qiáng)化灶。提示兩側(cè)大腦、小腦多發(fā)性感染灶，部分膿腫形成，結(jié)合臨床診斷為燒傷后顱內(nèi)多發(fā)性MRSA感染，部分膿腫形成。轉(zhuǎn)神經(jīng)內(nèi)科繼續(xù)穩(wěn)可信并加用磷霉素鈉抗感染，甘露醇脫水降顱壓等治療，一周后，因膿腫破裂出血死亡。譯文：Thepatient,male,36yearsold,wassenttohospital3hoursafterhew

5、asburntbyflamealloverhisbody.Examinationonadmission:36.1TC,P96times/min,R22times/min,patientwasinordinaryconditionwithconsciousmindandsmoothbreath.Theburntwoundspreadsinhead,neck,bodyand4limbs.Thebaseofburntwoundwasmostlyyellowishwhite.Diagnosisonadmission:Totalburntarea35%,IIdegreesuperficialburn15

6、%,IIdegreedeepburn20%.Afteradmission,thepatientreceivedtreatmentofindwellingcatheterbyrightfemoralveinpunctureconventionalfluidresuscitation,wounddebridement,headandfaceexposure,4limbsandbodywoundboundupexternallywith1%densitysulfadiazinesilverfrost,etc.20hoursafteradmission,patientsface,neckandboth

7、forearmswereobviouslyswelling.Hecomplainedtherewasmalaisefeelingofforeign-bodysensationinthroatandnumbnessinbothhandsfingers.Sotracheotomy,burntskinofbotharmsandsuperficialfasciaincisionreleasewerecarriedout.Thenthepatientsconditionwasimproving.5daysafterinjury,15%ofbotharms,leftcalfIIdegreedeepburn

8、twoundscabexcisionandmeshedautogenousskintransplantationwerecarriedoutunderintravenousanaesthesia.Afteroperation,cefoperazoneandetimicinwereusedtopreventinfection,and1%densitysulfadiazinesilverfrostwasstillappliedexternallyinIIdegreedeepburntfacewoundandbodywoundwhichwouldberefreshedonalternatedays.

9、Bacteriawasnotculturedfromwoundsecretion.5daysafteroperation,medicinewasrefreshedfor精品文檔scabexcisionandskingraftingwound.Theskingraftflapwaswelldeveloped.14daysafterinjurytracheacannulaswaspulledoffandthepatientcouldbreathesmoothlyandconditionwasstable.Allwoundareaswerehealedexcept1%ofIIdegreedeepbu

10、rntwoundinrightlowerabdomenandleftdorsalispedis.Duringtreatment,since11daysafterinjury,patientwasfoundhavehighfever,andthehighesttemperaturecouldreach40.1C,thenumberofperipheralleucocytesamountedto920.1x10/Lwithcentriole76%.Theadjustingantibioticwas2-drugmezlocillinandetimicinanti-infective.2dayslat

11、er,thenumberof9peripherialleucocytedroppedto11.4x10/Lwithcentriole86%.Bodytemperatureofpatientstillhadfluctuationandthehighesttemperaturereached38.9C.ChestX-rayinspectionfoundnoabnormalchangesinbothlungs.15daysafterinjury,patientwasfoundhaveagainshiveringandhighfever.Consideringtherewaspossibilityof

12、staphylococcusaureusinfection,therightfemoralveincatheterwaspulledoffandusdforbacteriaculture,antibioticwasadjustedintovincocin500mgq6hintravenousinfusion,andthewoundsecretionwasusedagainforbacteriacultureandbloodculture.3dayslater,veincatheter,woundsecretionandbloodbacteriaculturewereallmethicillin

13、resistantstaphylococcusaureusgrow(MRSA),beingsensitivetovancomycinthroughvitrodrugsensitivitytest.Continuetointravenouslydrippinginjectwithvancomycin,patientbodytemperaturedroppedtosomeextent,butgraduallyappearedsymptomsoflookingindifference,lazyspeaking,andlimbsweakness.After6daysofintravenousinfus

14、ionofvancomycin,leftupperextremitymusclestrengthweaknesswasfound(degreeIII).Craniocerebralinspectionwasmadeandindicated:thereweremultipleflakestyleT1,T2signaldensitywithobscurerealminrightcerebellahemisphere,temporallobeandfrontlobe.Pressurizedwatersequenceimageshowedhighsignal,enhancedscanshowedevi

15、dentringenhancementorincompleteenhancement,andpartial精品文檔cerebralsulcusandcerebralfissuregotnarrowed.Thebiggestfocusliedinrighttemporallobeandthesizewasabout3cmx2.8cm,andtherewerestillseperatedtinyspecksoffocusinbothsidesofbrainandleftcerebella.Itshowedtherewasmultipleinfectionfocusinbothsidesofbrai

16、nandcerebellaandsomeabscesshadformed.CombinedwithclinicdataitwasdiagnosedtobecerebralmultipleMRSAinfectionafterburntandsomeabscesshadformed.Patientwastransferredtoneurologydepartment,vancomycincontinuedtobeusedandcombinedwithfosfomycinsodiumtopreventinfectionwithtreatmentofmannitoldehydratingtoreduc

17、ecerebralpressure.Oneweeklaterpatientdiedofabscessrupture.討論：燒傷后感染等并發(fā)癥至今仍然是燒傷治療中棘手的問題之一，特別是多重耐藥細(xì)菌的感染并發(fā)癥。燒傷后并發(fā)顱內(nèi)感染雖然較少見，但仍有病例報(bào)道1，多見于兒童,成人也可發(fā)生。感染多為血源播散性,與嚴(yán)重?zé)齻髾C(jī)體免疫功能低下易發(fā)生侵襲性感染有關(guān)，也有醫(yī)源性因素如深靜脈導(dǎo)管的相關(guān)性感染所致2。感染的病源菌多與病區(qū)優(yōu)勢(shì)致病菌一致，如銅綠假單胞菌、金黃色葡萄球菌等。燒傷后由耐甲氧西林的金黃色葡萄球菌（MRSA）所致的顱內(nèi)感染較為少見，1992年Suzuki報(bào)道一例3。由于燒傷后顱內(nèi)感染早期多與侵

18、襲性感染癥狀相似，易漏診，腦膜炎癥后，對(duì)MRSA敏感的抗菌素如萬古霉素等難以透過血腦屏障，給治療帶來很大困難。本例燒傷面積為35%，燒傷創(chuàng)面主要分布在頭面部和四肢暴露部位，因常用的外周靜穿刺部位均被燒傷而選擇了深靜脈置管。在傷后2周創(chuàng)面基本愈合時(shí)，突發(fā)高熱、白細(xì)胞增高等全身感染表現(xiàn)，創(chuàng)面分泌物、深靜脈導(dǎo)管及血培養(yǎng)均培養(yǎng)出MRSA，結(jié)合病程、臨床表現(xiàn)和各項(xiàng)檢查，可診斷顱內(nèi)多發(fā)性膿腫源于右股靜脈導(dǎo)管的MRSA相關(guān)感染。盡管選用了敏感抗菌素，但萬古霉素難以透過血腦屏障，局部組織難以達(dá)到有效的殺菌濃度，最終治療失敗。燒傷后留置深靜脈導(dǎo)管，一旦發(fā)生導(dǎo)管感染和化膿性栓塞性靜脈炎，會(huì)給后續(xù)的病灶清除術(shù)帶來困

19、難，因此，有作者認(rèn)為，留置導(dǎo)管時(shí)應(yīng)盡量避免使用深靜脈4。但在臨床實(shí)際工作中，對(duì)大面積深度燒傷病例，留置深靜脈導(dǎo)管有時(shí)在所難免，精品文檔但要盡可能選擇血流速度快，不易形成血栓的部位，如頸內(nèi)靜脈、鎖骨下靜脈等。導(dǎo)管留置超過7日以上,特別是股靜脈部位,導(dǎo)管相關(guān)性感染的機(jī)率會(huì)明顯增加5。因此,達(dá)到治療目的后,應(yīng)盡早拔除,需要較長(zhǎng)時(shí)間使用的,應(yīng)定期重新穿刺,更換導(dǎo)管。本病例入院時(shí)因四肢常用的外周靜脈穿刺部位皮膚被燒傷,而選用了右股靜脈穿刺置管,但未能及時(shí)更換,且留置時(shí)間過長(zhǎng),增加了發(fā)生導(dǎo)管相關(guān)感染的機(jī)會(huì),應(yīng)特別引起重視。此外,留置深靜脈導(dǎo)管后,還應(yīng)加強(qiáng)插管部位皮膚的護(hù)理，保持局部干燥、清潔，導(dǎo)管內(nèi)使用抗

20、凝劑，采用抗生素鎖技術(shù)等也能有效地減少深靜脈導(dǎo)管相關(guān)性感染的發(fā)生。譯文：Discussion:1992inSuzukionecasewasreported.Becouseintheearlyperiodthesymptomsofcerebralinfectionafterburntaresimilartothoseofinvasiveinfections,misseddiagnosistendstohappen.Aftermeningococcaldisease,antibioticssensitivetoMRSAsuchasvancomycinaredifficulttopasstheblo

21、od-brainbarrierwhichcausesbigdifficultiestotreatment.Inthiscasetheburntareais35%,burntwoundmainlyspreadsintheexposedpartsofhead,face,and4limbs.Becoursecommonlyusedperipheralveinpuncturepartswereallburnt,thedeepveinindwellingwasselected.精品文檔Whenthewoundareawasbasicallyhealed2weeksafterinjury,symptoms

22、ofsystemicinfectionsuchashighfeverandincreasedleucocytessuddenlyoccurred.Woundsecretion,deepveincathetersandbloodcultureallculturedoutMRSA.Combinedwithdiseasecourse,clinicfeaturesandvarietyofexaminations,itcanbediagnosedthatmultiplecerebralabscesswascausedbyMRSAinrightfemoralveincatheterrelatedinfec

23、tions.Althoughsensitiveantibioticswereused,vancomycinwasdifficulttopassblood-brainbarrier,andlocaltissuewasdifficulttoachieveeffectivebactericidalconcentrationwhichleadedtotreatmentfailurefinally.Thedeepveincatheterremainedinbodyafterburnt,ifonceinfectedandsuppurativethrombophlebitishappened,willbri

24、ngdifficultiestothesubsequentdiseasefocusdebridementsurgery.Sosomeauthorthinksitshouldavoidemployingdeepveinwhileindwellingcathetersasmuchaspossible.Butinpracticalclinicwork,inextensivedeepburnmedicalcase,deepveincatheterindwellingissometimesinevitable,andtheplacewherebloodcirculatesfastandthrombusd

25、oesnoteasilyformshouldbeselected,suchasthejugularveinandsubclavianvein.Ifcatheterremainsmorethan7daysespeciallyintheplaceoffemolavein,thechanceofcatheterrelatedinfectionwillbeincreasedapperantly.Thereforethecathetershouldbepulledoffasearlyaspossibleoncethetherapeuticpurposesareachieved.Iflongtimeuse

26、isnecessary,itshouldbere-puncturedatregularintervalsandrenewthecatheter.Inthiscase,becoursethecommonlyusedperipheralveinpuncturepartsof4limbsareburntonadmission,therightfomelaveinpunctureindwellingwasselected.Butcatheterwasnotrenewedtimely,anditremainedfortoolongatimewhichincreasedthechanceofcathete

27、rrelatedinfection.Thisshouldbepaidspecialattentionto.Inaddition,afterdeepveincatheterisremained,intensivecareshouldbegiventotheskinofindwellingpartsandkeepdryandcleanlocally.Anticoagulationagentshouldbeusedincatheter,andtheantibioticlock精品文檔technologycanalsoreducethechanceofdeepveincatheterrelatedinfectioneffectively.參考文獻(xiàn)：1林源.小兒大面積燒傷晚期并發(fā)腦膿腫一例.中華燒傷外科雜志,2001,17:592.2001,27:662-663.3SuzukiT,UekiI,IsagoT,etal.Multiplebrainabscessescomplicatingtrea